Delta Doctors Program – Affidavit and Agreement

Effective: October 15, 2022

Delta Regional Authority

J-1 Visa Waiver Program

Affidavit and Agreement

I, ______________________________, being duly sworn, hereby request the Delta 

Regional Authority (DRA) to review my application for the purpose of recommending a

waiver of the foreign residency requirement set forth in my J-1 Visa, pursuant to the terms 

and conditions as follows:

1. I understand and acknowledge that the review of this request is discretionary and that in 

the event a decision is made not to grant my request, I hold harmless DRA, the Federal CoChairman, any and all DRA employees and representatives from any action or lack of 

action made in connection to this request. 

2. I further understand and acknowledge that the entire basis for the consideration of my 

request is DRA’s desire to improve the availability of primary and specialty medical care 

in areas designated by the Secretary of the U.S. Department of Health and Human Services

as a Health Professional Shortage Area (HPSA), Mental Health Professional Shortage Area 

(MHPSA), Medically Underserved Area (MUA), or Medically Underserved Population 

(MUP) within DRA’s congressionally-mandated footprint. I understand DRA only 

provides J-1 visa waiver recommendations for physicians practicing at work sites located 

within DRA’s congressionally-designated footprint, and I agree to practice therein. 

Furthermore, I understand the sponsorship of any waiver by DRA is strictly voluntarily. 

3. I understand and agree that in consideration for a waiver, which eventually may or may not 

be granted, I shall render primary or specialty medical care services to patients, including 

the indigent, for a minimum of forty (40) hours per week, or 160 hours per month, within 

a designated HPSA, MUA, MHPSA, or MUP located within DRA’s congressionallymandated footprint. Unless there are extenuating circumstances which DRA approves, 

such service shall commence no later than 90 days after I receive approval by USCIS of 

my waiver request and shall continue for a minimum of three years or longer in accordance 

with the employment contract.

4. I understand and acknowledge that DRA does not provide letters of support or no objection 

for any instances of change in employment status. DRA cannot and does not determine 

extenuating circumstances.
Delta Doctors Program – Affidavit and Agreement

Effective: October 15, 2022

5. I agree to incorporate all the terms of this “J-1 Visa Waiver Affidavit and Agreement” into 

any and all employment agreements I enter pursuant to paragraph 3 and to include in each 

such agreement DRA’s liquidated damages clause, payable to the employer (a copy of all 

employment agreements are attached to this request). This damages clause shall be 

activated by my termination of employment, initiated by my employer for cause or by me 

for any reason, only if my termination occurs before fulfilling the minimum three-year 

service requirement. In the event of a transfer under DRA’s liquidated damages clause, a 

transfer notification form must be obtained by DRA. I will ensure that this form is 

completed and returned to DRA with a copy to the State Contact. 

6. I further agree that any employment agreement I enter pursuant to paragraph 3 shall not 

contain any provision, which modifies or amends any of the terms of this “J-1 Visa Waiver 

Affidavit and Agreement.”

7. I understand and agree that I will provide health services to individuals without 

discriminating against them because: (a) they are unable to pay for those services or (b) 

payment for those health services will be made under Medicare or Medicaid.

8. I have read, signed, and fully understand the “DRA J-1 Visa Waiver Program Guidelines”, 

a copy of which is attached to this request. 

9. I expressly understand this waiver of my foreign residence requirement must ultimately be 

approved by the USCIS, and I agree to provide placement notification of the specific 

location and nature of my practice to DRA when I commence rendering services within 

DRA’s congressionally-mandated footprint.

10. I declare and certify, under penalty of the provisions of 18 U.S.C. 1101, that I do not have 

pending nor am I submitting during the pendency of this request, another request to any 

United States Government department or agency or any State Department of Public Health, 

or equivalent, other than DRA to act on my behalf in any matter relating to a waiver of my 

two-year home-country physical presence requirement. 

11. I understand and acknowledge that if I willfully fail to comply with the terms of this “J-1 

Visa Waiver Affidavit and Agreement,” DRA’s Office of the Federal Co-Chairman will 

notify the USCIS that I am out of compliance. Additionally, any and all other measures 

available to the Office of the Federal Co-Chairman will be executed in the event of my 

non-compliance. 
Delta Doctors Program – Affidavit and Agreement

Effective: October 15, 2022

I declare under the penalties of perjury that the foregoing is true and correct. 

Physician’s Signature: _________________________________________

Physician’s Name: ____________________________________________

Subscribed and sworn before me this ______ day of ______________________, 20_____. 

__________________________________________ (Notary Public)